The current standard practice involves conducting a complete trauma laparotomy, characterized by an incision extending from the xiphoid process to the pubic symphysis. A comprehensive assessment of the abdomen consists of inspection of the hollow viscus organs and the solid organs, performing Kocher maneuver to inspect the duodenum, and create access to the lesser sac for inspection of the posterior stomach site of and the pancreas. Other procedures such as Pringles maneuver, Cattell-Braasch maneuver, and colon mobilization are selectively performed if indicated by suspicion of injuries. Laparoscopy can be useful to establish a minimally invasive overview and initially diagnosis on which further examinations and decisions can be based. Moreover, most surgeons will be able to handle the basic steps of explorative and diagnostic laparoscopy.
Our study found a high rate of non-therapeutic laparotomies of 28% in stable patients presenting with penetrating abdominal trauma. Laparotomies performed without any intraabdominal findings were 20%. Internationally, also including high-volume centers, wide incidences of negative laparotomies are reported ranging from 3,9–61% [3–5, 10, 13, 14]. The rate of non-therapeutic laparotomies seems to be higher in patients with stable penetrating abdominal trauma, and laparoscopy could therefore have an important role in reducing the rate of non-therapeutic laparotomies in this specific patient category. Moreover, the group mainly consists of young and healthy individuals, who receive an intervention associated with substantial morbidity.
With hemodynamically stable patients, there is ample time to conduct a thorough diagnostic laparoscopy.
The decision to initiate with laparotomy is primarily based on assumed penetration of the peritoneum on the CT scan, though we found intact peritoneum in seven patients in the laparotomy group. In all seven instances, the CT scans showed doubtful intraabdominal findings, e.g. only with small amounts of free air which often was located at the point of penetration. The most frequent trauma mechanism is stab wounds and the penetration will lead air along the stab canal. If the lesion stops just before the peritoneum it can be difficult to determine whether the air is located intraabdominal or between the fascia and peritoneum. In the laparoscopy group another seven patients were converted to laparotomy without further findings. These seven patients were all patients with a negative E-FAST and CT scan before surgery. Overall, we have to interpret the findings on CT scans more cautiously and since the patients are hemodynamic stable, these patients can benefit from an initial explorative and diagnostic laparoscopy and likely avoid a laparotomy.
The most injured organs are stomach, liver, diaphragm, small bowel and colon, and account for a total of 68% of all injuries. These are all organs where it is feasible to visualize and inspect the injuries by laparoscopy and therefore laparoscopy will in many cases be sufficient to find the needed injuries. In our study 31% of the patients only had a single injury requiring surgical intervention which most surgeons are expected to be able to handle laparoscopically, for example a hemostatic patch on a liver bleed, suturing of a stomach perforation, suturing of a diaphragm lesion, etc. If a laparotomy is needed to handle the injury diagnosed laparoscopically, e.g. in case of a small bowel resection, we can target the incision, and therefore avoid a full trauma laparotomy.
Most surgeons trained in laparoscopy will manage to create access to the lesser sac, but Kocher maneuver may be more challenging and may increase the risk of iatrogenic damage to duodenum. If it is required to review the abdomen using more advanced procedures, there will be a substantial probability that the injuries are so severe, that it will not be beneficial to address it laparoscopically. Under any circumstances, it is relevant to consider the trauma mechanism and location to a greater extent, and create a personalized approach for the individual patient. E.g. a single stab wound on the anterior part of the abdomen which has not caused any damage to the nearest organs in front, will unlikely have caused damage to the posterior located organs. Therefore, if there are no visible injuries at the anterior wall of the organ, it should not be indicated to look in the lesser sac or perform a Kocher maneuver.
Laparoscopy appears to be an obvious way of identifying intraabdominal injuries after penetrating trauma in the hemodynamic stable patient and may likely lead to a decreased number of non-therapeutic laparotomies. More research is needed to clarify whether diagnostic laparoscopy is safe in the trauma setting and is able to identify all injuries before laparoscopy is going to be implemented as a standard treatment in this patient group. Moreover, a clear definition is required of what a sufficient diagnostic laparoscopy in trauma should consist of. Ultimately, choice of treatment must always depend on the expertise of the individual surgeon. Therefore, we need to train the relevant surgeons to increase expertise and skills. Laparoscopy must be an integrated part in the education to become a trauma surgeon in the future.
Limitations
The retrospective study design is a limitation and data are only extracted from a single center, thus data are not necessarily comparable with other centers. Due to the limited number of patients included and especially the low number of laparoscopies performed, we cannot draw firm conclusions on the safety of laparoscopy in trauma. Especially, because laparoscopy in this study is only performed in an exploratory manner and not used as either diagnostic or therapeutic.